• Rapid Review: Seizures & Midazolam

    by Dr. Christine Tomkinson. Last modified: 23/06/14



    Simple Partial

    • Focused area such as temporal lobes or  hippocampi
    • Fear, anger, sadness, happiness or nausea
    • Sensation of falling or movement
    • Unusual feelings or sensations
    • Altered senses
    • Derealisation or depersonalisation
    • Spatial distortion
    • Déjà vu or jamais vu
    • Laboured speech or inability to speak


    Complex Partial

    • Unilateral cerebral hemisphere involvement
    • +/- simple partial as aura preceding
    • Automatisms
    • Amnesia
    • Altered consciousness
    • Impairment of awareness



    • Tonic-clonic
    • Tonic
    • Clonic
    • Myotonic
    • Absence
    • Atonic

    Status Epilepticus

    • 10 minutes of continuous seizure activity
    • Seizures >5 mins need aggressive management


    • Rainbow et al. (2002) found that midazolam can control seizures as effectively as diazepam in the prehospital setting.
    • Intranasal midazolam can also result in a comparable time to cessation of seizures to that of intravenous diazepam (Lahat et al., 2000)
    • Wolfe & Macfarlane (2006) found that intranasal midazolam can provide better seizure control than PR diazepam, and is easier for paramedics to administer to a patient who is actively seizing.
    • A number of authors (Scott et al, 1999; Queally, 2007; Wilson et al., 2004; Humphries & Eiland, 2013) also found that patients and caregivers found intranasal midazolam to be more socially acceptable than per rectum administration of diazepam, as well as re-confirming the view it was more convenient for paramedics to access the intranasal route than the per rectum route.
    • Queally (2007) concluded that buccal midazolam may be useful in the community setting in the treatment of prolonged and serial seizures and the prevention of status epilepticus.
    • Chamberlain et al. (1997) concluded that IM midazolam is an effective anticonvulsant for children with seizures and an important alternative when IV access is not available.
    • Where intravenous access is unavailable there is evidence from one trial that buccal midazolam is the treatment of choice (Appleton et al., 2008)

    (full references at prehospitalresearch.eu/?p=1828)

    Review article

    Silbergleit R, Lowenstein D, Durkalski V, Conwit R; NETT Investigators. Lessons from the RAMPART study–and which is the best route of administration of benzodiazepines in status epilepticus. Epilepsia. 2013 Sep;54 Suppl 6:74-7.

    • Patients treated with IM midazolam were more likely to have stopped seizing at emergency department (ED) arrival
    • Patients treated with IM midazolam  were less likely to need emergency medical services (EMS) rescue therapy
    • Patients treated with IM midazolam were less likely to require any hospitalization or admission to an intensive care unit

    Check out the Canadian Prehospital Evidence Based Practice Database recommendations on seizure management – https://emspep.cdha.nshealth.ca/LOE.aspx?VProtStr=Seizure%20(Adult)&VProtID=126

    Related content



    Rainbow J1, Browne GJ, Lam LT. Controlling seizures in the prehospital setting: diazepam or midazolam? J Paediatr Child Health. 2002 Dec;38(6):582-6. PMID: 12410871.


    Lahat E1, Goldman M, Barr J, Bistritzer T, Berkovitch M. Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study. BMJ. 2000 Jul 8;321(7253):83-6. PMID: 10884257.


    Wolfe TR1, Macfarlane TC. Intranasal midazolam therapy for pediatric status epilepticus. Am J Emerg Med. 2006 May;24(3):343-6. PMID: 16635708.


    Scott RC1, Besag FM, Neville BG. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. Lancet. 1999 Feb 20;353(9153):623-6. PMID: 10030327.


    Wilson MT1, Macleod S, O’Regan ME. Nasal/buccal midazolam use in the community. Arch Dis Child. 2004 Jan;89(1):50-1. PMID: 14709505.


    Humphries LK1, Eiland LS. Treatment of acute seizures: is intranasal midazolam a viable option? J Pediatr Pharmacol Ther. 2013 Apr;18(2):79-87. PMID: 23798902.


    Chamberlain JM1, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, Waisman Y. A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Pediatr Emerg Care. 1997 Apr;13(2):92-4. PMID: 9127414.


    Silbergleit R1, Lowenstein D, Durkalski V, Conwit R; NETT Investigators. Lessons from the RAMPART study–and which is the best route of administration of benzodiazepines in status epilepticus. Epilepsia. 2013 Sep;54 Suppl 6:74-7. PMID: 24001080.

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    Dr. Christine Tomkinson

    Dr. Christine Tomkinson

    BSc BMBS Resident Physician, Neurology
    Christine is a Resident Physician in Neurology based in Ontario, Canada. She studied at the University of Guelph, Ontario and the University of Limerick, Ireland. Her main interests are stroke, dementia care and multiple sclerosis.

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